Consultation Module Key Refs

Front 1

Medicine is not purely an objective science but contains a lot of subjectivity about illness and suffering.

Often the prevailing paradigms of modern medicine fail to capture what it means to be ill and what it means to be a doctor

Back 1

Good/Greenhalgh 2013

Front 2

Psychoneuroimmunology

Back 2

Berczi

Front 3

If doctors surrender their legacy of scientific rationalism completely the consultation is left FLOUNDERING IN A POST-MODERN VOID where neither person is sure of the other’s expertise

Back 3

Taylor 2008

Front 4

Comms skills:
Low level of challenge
Banal
We should provide people with a language
Teach by inviting reflection about skills, and then that will let them see the need for skills

Back 4

Skelton 2005

Front 5

These chaps produced checklists to assess the degree of patient/doctor centredness

Back 5

Byrne & Long 1976

Front 6

Consultation is the interface between two people, but also the medical profession and society

Back 6

Taylor 2008

Front 7

Doctors need to be bilingual - language between HCPs and between Pts

Back 7

Taylor 2008

BUT there is an increasing desire for patients to understand the medical tongue (woman who has handcuffed after requesting to see her notes)

Front 8

Doctors need to be systematic in terms of what info they gather, but flexible in the way the go about it

Back 8

Taylor 2008

>20% of primary care consultations remain unexplained
60% are self-limiting

Front 9

Calgary-Cambridge Steps and ref

Back 9

Silverman 1998

Initiating the session
Gathering information
Physical Examination
Closing the session

Throughout:
Providing structure, building the relationship

Front 10

Looked at effect of directing and sharing style on consultation
*Directing* style: Significantly higher satisfaction (esp. PHYSICAL problems and those wanting prescription)

Back 10

Savage

Front 11

Looked at measuring QUALITY OF CARE in GP consultations, and to determine what correlates with enablement (what is enablement?)

Enablement associated with duration of consultation and knowing the doctor well

Back 11

Howie

Enablement: 'The extent to which a patient is capable of understanding and coping with his/her health issues'

Reward with QOF point?

Front 12

RCT of PCC in diabetes - how it inpacts current welbeing and future disease risk

Intervention group: Better communication, greater treatment satisfaction and wellbeing

BUT higher BMI levels and triglyceride levels

Back 12

Kinmonth

Drs should not lose focus on disease management

Front 13

75% of patients want a 'patient centred' approach

Back 13

Little 2001

Front 14

What are the six interactive components of the patient centred clinical method? Who came up with them?

Back 14

Stewart 2005

Explore illness experiences as well as disease
Understand the whole person
Find common ground (central tennant - SDM)
Opportunisitc health promotion
Enahnce the doctor-patient relationship
Be realistic

Front 15

What does 'whole person' practice include?

Back 15

Openness on the part of the doctor to learning about all dimensions of the patient's problem
Willingness to meet the patient at an emotional level (cognitive and emotional)

BUT does the biomedical model provide necessary distance?

Front 16

Currently, society values individual accomplishment above community, science over art and technological solutions over wisdom

Back 16

Stewart 2005

Note: Illich
Note: T.S. Eliot's poem

We have a diminished capacity for spirituality and love

Front 17

We should look at the wider context but *avoid the reductionist perspective of breaking down caring into minute skills and behaviours*

Back 17

Stewart 2005
Skelton 2005

Front 18

There is a lack of clarity over what PCC means for patients or HCPs

Back 18

Taylor 2008

Front 19

Challenges for patient centredness, and guy who presented them (5)

Challenge to consultation: Profusion of alternative means of accessing information

Back 19

Taylor 2008:
Co-modification of healthcare
Information revolution
Tension between choice and continuity
Medicalisation
Availability of resources

Front 20

Patients are more satisfied in consultations in which their ideas and concerns are addressed (PCC).

Back 20

Little 2001

Front 21

PCC is particularly appreciated wrt psychosocial problems

Back 21

Winefield
Launer

Front 22

PCC appears beneficial for both doctors and patients.

Also, this chappie pointed out certain dimensions of the dr-pt relationship to be beneficial:

Back 22

Griffin

Clear information
Mutually agreed upon goals
An active role for the patient
Positive affect and empathy

Encourage patients to ask questions and write down their concerns

Front 23

A third of cancer patients wanted to defer treatment decisions to their doctor (despite evidence in vignettes of people saying they don't want to)

Back 23

Degner

Front 24

Some patients prefer a directing style, especially those with physical complaints, or those requesting prescriptions

Back 24

Savage

The elderly also want this BUT they are the ones with long term chronic issues!

Front 25

Biomedical model offers a degree of separation between doctor and patient, which avoids devastation

Back 25

Segal

Front 26

Most patients want to see the road map, including alternative routes, even if they don't want to take over the wheel

Back 26

Kravitz

Front 27

True PCCs mean being aware enough to recognise the patient's preferred style and being adaptive enough to respond accordingly

Back 27

Taylor 2008

Front 28

Involving patients in decision making can be a challenge - consider statistics that can be presented in many different ways (some more pursuasive than others)

Back 28

Taylor 2008

Front 29

There is a challenge between improving population health and respecting the value of the individual

Back 29

Taylor 2008

Consider all the screening GPs have to do - 'A parrot could do my job'

Front 30

Tasks to resolve the difficulties of PCC:

Back 30

Allow sufficient time
Acknowledge uncertainty
Use visual aids/analogies

Front 31

Having the patient make the choice may mean it is an 'irrational one' - but we are not the patient, and allowing them to do so helps build a more honest relationship over time

Back 31

Taylor 2008

Front 32

The incessant data gathering exercises subvert the patient narrative

Back 32

Taylor 2008

Front 33

Willis quote

Back 33

The greatest challenge facing contemporary medicine is for it to retain (or regain) its humanity and caritas *without losing its essential foundation in science*

Front 34

Ways to achieve the 'middle way' between science and art of medicine

Back 34

Stewart 2005:
Teach science of med as linked with art of med
Teach value of relationships without being reductionist
Teach that there is more to the patient than just the person in front of you (sometimes)
Engage patients as allies in teaching (encourage questions)
Lead by example

Front 35

The potential of a consultation is to individualise and interpret the evidence appropriately whilst taking into account the patient's unique circumstances

EBM need not treat every patient as standard, but may still make evidence available for every patient as part of the DM process

Back 35

Taylor 2008

Front 36

There is a need in consultations to 'tap into' a patients more creative side - guidelines may subvert this

Back 36

Stewart 2005

Front 37

There is a need to address the patient's narrative, but the doctor is ALSO under the obligation to objectify, code and structure the info he receives

Back 37

Taylor 2008

Communication becomes an exercise in naming rather than healing

Front 38

Heartsink patients exist because our scientific and medical training, hurried working conditions and unsupported professional needs CONCENTRATE OUR PREFERENCE FOR STANDARD BEHAVIOUR

Back 38

O'Dowd

Front 39

Doctors adopt a 'hypothetical-deductive' approach

Back 39

O'Dowd

Front 40

There is an increasing culture where the patient's account can only be legitimised by diagnosis and treatment

The issue goes BEYOND doctors

Back 40

Taylor 2008

At times IT IS PATIENTS who seek reductionist interpretations

Front 41

What did Howie state wrt consultation quality?

Back 41

Created 'Consultation Quality Index'

Included topics:
Able to cope with life
Able to understand illness
Able to cope with illness
Able to keep yourself healthy
Confident about your health
Able to help yourself

Front 42

Few patients voiced all their agendas in the consultation in this study

Back 42

Barry 2000

BUT: Only 35 patients

Front 43

Consequence of unvoiced agendas?

Back 43

Major misunderstandings
Unwanted prescriptions (up costs)
Lack of adherence to treatment

Front 44

This study: Patients strongly wanted a patient centred approach

Back 44

Little 2001

Front 45

Study using vignettes to see if patients wanted to be involved in decision making in the consultation.

Physical issues, age and higher social class --> Preferred directed approach

But there were large minorities in each group

Back 45

McKinstry 2000

Front 46

Patients more likely to describe their own doctor's style as similar to the one they preferred

Back 46

MicKinstry 2000

Front 47

Doctors need the skills, knowledge of patients and time to determine on which occasions, and with which illnesses their patients wish to be involved in DM

Back 47

McKinstry 2000

Front 48

Multivariate regression showed that GP patient-centred behaviours did not predict patient satisfaction or enablement

Back 48

Mead 2002

Front 49

Systematic review to assess outcomes of PC approach

Name and findings

Back 49

Dwamena 2012

Interventions to promote PCC effective
BUT effects on pt sat, health behaviour and health status are mixed

Front 50

Ability for patients to voice their agenda largely dependent on the style of communication adopted by the doctor

Back 50

Barry 2000

Front 51

It can be dangerous to elevate the dr-pt relationship too high.

Get stuck in a rut with 'difficult' patients. Doctors have a feeling they can't express their own concerns or judgements (for fear of damaging the lauded long-term relationship)

Back 51

Chew-Graham 2004

Front 52

High focus on Dr-Pt relationship existed since WWII and imposed by Balint and his followers - who had a heavy influence on RCGP performance

Back 52

Balint

Front 53

Doctors have overestimated the importance of sustaining their relationship when doing so only maintains incapacity

Back 53

Chew-Graham 2004

Front 54

Shared decision making as balancing patient and doctor power (ritual verses genuine sharing - not just letting patient know)

Back 54

Elwyn 1999

Front 55

'Scientific' imbues value - patients seen as irrational if they don't comply

Back 55

Elwyn 1999

Front 56

The dr-pt relationship is the most important variable in compliance

Back 56

Elwyn 1999

Front 57

Diagnosis strategy

Initiation --> Refinement of diagnostic causes --> Defining final diagnosis

Back 57

Heneghan

Front 58

What is a 'diagnosis'?

Back 58

Knottnerus
Increasing certainty about the presence/absence of a disease. Gives idea of severity, and the ability to monitor the course of disease and prognosis as well as to plan treatment

Front 59

There is a need to enhance the 'second half' of the consultation (the time at which the nature of the problem and therapeutic actions are discussed)

Back 59

Elwyn 1999

Front 60

Who developed the SDM model and what does it look like?

Back 60

Elwyn 1999

Paternalism <-> SDM <-> INFORMED CHOICE

Front 61

Characteristics of SDM (and who wrote these)

Back 61

Elwyn 1999

Involves at least two participants
Both parties take steps to participate in the process of treatment decision-making
Information sharing is a prerequisite to SDM
A treatment decision is made and both parties agree

Front 62

A shared approach is not always appropriate, especially when followed mechanically or ritualistically

Back 62

Elwyn

Front 63

A patient's desire for information is stronger than their desire to be involved in DM

Back 63

Don't want to take the wheel, but do want to see the map

Link between preferences for participation and actual participation is not that strong

Front 64

SDM: Consider patients who lack capacity and levels of 'informed consent'

Is an informed choice model a consequence of doctors consulting defensively who fear medicolegal issues?

Back 64

Elwyn 1999

Front 65

The principle of autonomy is not necessarily beneficial, and may conflict with the equally valid principle of beneficence

Back 65

Elwyn 1999

Front 66

SDM matches 'relationality' ethical principle - meaning?

Back 66

It promotes the provision of accurate, honest information IN THE CONTEXT OF THE INDIVIDUAL SITUATION

So some may want to be passive, others active (consumerist)

Front 67

Why doesn't SDM occur?

Back 67

Elwyn 1999
Threatening to 'power' relationship
CoC means its hard to change an established model
Drs thing pts might not like Dr uncertainty
Traditional med training does not teach doctors to share decisions

Front 68

Participation in SDM is increased when physicians exhibit patient-centred behaviours

Back 68

Elwyn 1999

Front 69

A mood of questioning consumerism and the unprecedented electronic access to information is re-defining the role of the generalist

Back 69

Elwyn 1999

Front 70

Patients do not take medications so doctor orders further test. Real problem is that they can't explore their narrative and don't tell dr they're not taking their meds

Back 70

Segal 1994

Front 71

Medicine and science carry kudos - makes sense to expect compliance and view patients as being irrational when they don't take their medications

Back 71

Segal 1994

Front 72

Biomedical model offers a degree of separation between doctor and patient - this avoids devastation

Back 72

Segal 1994

Front 73

Biomedical paradigm is made in a theory of biological reductionism. It is the dominant paradigm in western med and the one taught and learned in medical schools

Back 73

Segal 1994

Front 74

Who characterised biomedicine, and what are the characteristics?

Back 74

Stein
Covers basic sciences
Basic science should be rational, dispassionate and have objective judgement
Disease can ultimately be understood in terms of pathological entity - organic in nature and treatment that is optimal consists of a technological procedure or intervention that results in a cure
Believes that medical knowledge and skills are best organised by creating specialities around organ systems

Front 75

Dr-pt relationship is the most important variable in compliance

Back 75

DiNicola

Front 76

Biomedical model does include the examination

Back 76

The physical, intimate touch - all are treated equally. Medicine is charitable and egalitarian

- Patient's guaranteed acceptance and care no matter who they are or what their lives have been

Touch is not irreducible, because it is partly social

Front 77

There is an incommensurable dialogic between doctors and patients - they do not speak the same language

Back 77

Hunter

How doctors relate to their patients is critical in affecting the adherence process

Front 78

Science takes control of body (soma) during enlightenment (17C) and church focuses on soul

Back 78

Could make an interesting point - if we ARE just all cells then perhaps one day altering 'brain chemistry' could be a viable treatment option

Front 79

You can't treat the patient in a purely positivistic manner

Back 79

Paternalism can focus on the patient's agenda (if that's what they want)

Front 80

Being pt-centred is giving space for exchange of the doctor's and patient's knowledge in both directions

Back 80

Greenhalgh (and Heath - 'Bridge')

Front 81

Briefly explain the phenomenological model

Back 81

Where the question is not 'what is the diagnosis' but 'who is the patient and what is he/she going through' - Views not around doing something to the patient, but being there fore them (care not cure relationship)

Front 82

Briefly explain the psychodynamic model

Back 82

Idea that GP is the vehicle through which painful subconscious (emotional) issues are brought for discussion (the hidden agenda)

Use of professional position to promote emotional (and therefore, physical symptomatic) healing in patients (Balint - DOCTOR AS DRUG. OKAY THIS MAKES SENSE YOU CAN DOOOOO IT)

Front 83

If you understand the patient and their PoV, you are more likely to be able to progress from their standpoint to another that you might think is better

Back 83

Difference between being pt centred and acting in the patient's best interest?

Front 84

Patient-Practitioner Orientation Scale - a way of measuring Pt-centredness

Back 84

Also: MAAS-GP and OPTION

Front 85

Assessing patient centredness with a questionnaire may be reinforcing idea of patient as consumer

Back 85

Some patients will give high marks easily, others will not

Front 86

Policy --> 'no decision about me without me'

Back 86

Modernist research - quantitative and positivist truth as correctness
Postmodern research - qualitative - Truth as aletheia/revealing

Front 87

Having a leadership and hierarchy can predict patient satisfaction (Said who?)

Back 87

Lancaster University Management School

Front 88

The way staff view their leaders is strongly related to patients perceptions of quality of care

What is the impact of the 'dumbing down' of hierarchy for patients?

Back 88

Lancaster University Management School

Note: Command and control cultures are not healthy, there is a difference between them and a well respected hierarchy

Front 89

Staff commitment and satisfaction influence patient satisfaction

Back 89

Lancaster University Management School

Front 90

Poor staff health and wellbeing --> Patients less satisfied, poorer care received, financial performance of hospital is worse (could be reverse causality?)

Back 90

Lancaster University Management School

Front 91

If there is high work pressure, patients report too few nurses, insufficient support, privacy and respect

Back 91

Lancaster University Management School

Front 92

Ability of staff to influence and contribute to improvements (autonomy) results in lower mortality

Back 92

Lancaster University Management School

Front 93

Recruitment process is an auspicious time to communicate the values of an organisation - New people need to see compassion, challenging of rudeness and instability and see what is valued

Back 93

West (Lancaster University Management School)

Front 94

NHS is remarkable in how well trained, skilled, motivated and intelligent its staff are! We should dedicate time to understand what their views are, problems are, and solutions are

Back 94

LUMC

Well constructed teams --> Lower mortality

Front 95

This dude examined PCC and SDM to see whether they're different and found they're weakly associated

Back 95

Wensing 2002 (an unintuitive result, considering that 'common ground' is a key part of PCC

Front 96

Women may be favoured in providing a more PC consultation - use more cooperative language and have stronger interpersonal associations

Back 96

Men more reserved and less empathetic

Front 97

Ways of measuring PCC

Back 97

MAAS-GP scale (Robinson found this to have content-validity)
OPTION tool
Patient-Practitioner Orientation Scale

Front 98

Current timing and funding constrains may need to be reconstructed if we are to have effective SDM

Back 98

Charles

Front 99

Continuity of care improves uptake of preventative care

Back 99

Gray

Front 100

CoC results in advice becoming less strict but enhances compliance and satisfaction

Back 100

Gray

Front 101

Patients desire CoC (but young males tend to value it less, and with mechanical issues it is less important)

Back 101

Gray

Front 102

Primary care would be impoverished by moves away from continuity

Back 102

Gray

Front 103

Chap who did a study on patient centredness in first years. More associated with females, and those with a patient centred attitude tended to be more interested in primary care

Back 103

Krupat 1999

Front 104

Teaching patient centredness has an impact

Patients expressed more fears, and residents engaged in more 'facilitating behaviour'

Back 104

Stewart

Front 105

Identification of culture/ethnicity not always simlpe

Back 105

Daniella

Some deaf people see themselves as being in their own cultural group

Front 106

Ethnic group measurement is somewhat political, and changes over time

Back 106

Nazis redefined what it meant to be Jewish

Front 107

Doctors have to consider things like gelatin in medicines

Back 107

And festivals like ramadan